PA Student Application to attend the 2024 REPRESENT! NCCPA Summit

The Westin Peachtree Plaza, Atlanta, Georgia

The REPRESENT! NCCPA Summit starts at 7 a.m. on Monday, Sept. 16th, with breakfast, followed immediately by sessions. The Summit ends at 5 pm Sept. 17th after a visit to The National Center for Civil and Human Rights (self-guided tour).

PA students in good standing are encouraged to apply to get free attendence, meals, travel and hotel stay.

Deadline for registration is June 1st, 2024. Please notify us by email pr@nccpa.net with any questions or cancellation.

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* 1. First Name:

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* 2. Last Name with Credentials:

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* 3. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 4. Do you have any dietary restrictions? (Select all that apply.)

I do not have any dietary restrictions.

Vegetarian

Vegan

Gluten Free

No Shellfish

No Nuts

No Dairy

Other (please specify)

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* 5. Do you have any special needs that may require accommodations to fully participate?

None

Audio

Mobility

Visual

Other (please specify)

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* 6. I will attend the reception event on Monday, Sept. 16th at The Overlook at Westin Peachtree Plaza.

Yes

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* 7. I would like to receive a complimentary ticket to The National Center for Civil and Human Rights for a group event (self-guided tour) on Tuesday, Sept. 17th, starting at 3 p.m.

Yes

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* 8. Which PA Program are you attending?

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* 9. PA Program anticipated graduation date:

Date

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* 10. Please enter the contact information of faculty from your PA program. We will contact them to ensure you can take the time from your academic or clinic coursework to attend. Please let them know that you are applying to attend.

Faculty Advisor Name

Faculty Advisor Email

Program Director Name

Program Director Email

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* 11. Essay: Please discuss in 500 words or less one of the following topics:
1. What role do you believe a diverse PA workforce plays in the delivery of patient care?
2. Please list any prior work you have done, or are currently doing, related to increasing racial/ethnic diversity in the PA profession.
3. What do you hope to learn from attending the REPRESENT! NCCPA Summit?

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* 12. Are you interested in submitting an abstract for the poster session?
July 1, 2024: Poster application deadline
August 1, 2024: Notification to applicants

Yes

Still thinking about it

PA Student Application to attend the 2024 REPRESENT! NCCPA Summit

The Westin Peachtree Plaza, Atlanta, Georgia

Question Title

* 1. First Name:

Question Title

* 2. Last Name with Credentials:

Question Title

* 3. Address

Question Title

* 4. Do you have any dietary restrictions? (Select all that apply.)

Question Title

* 5. Do you have any special needs that may require accommodations to fully participate?

Question Title

* 6. I will attend the reception event on Monday, Sept. 16th at The Overlook at Westin Peachtree Plaza.

Question Title

* 7. I would like to receive a complimentary ticket to The National Center for Civil and Human Rights for a group event (self-guided tour) on Tuesday, Sept. 17th, starting at 3 p.m.

Question Title

* 8. Which PA Program are you attending?

Question Title

* 9. PA Program anticipated graduation date:

Question Title

* 10. Please enter the contact information of faculty from your PA program. We will contact them to ensure you can take the time from your academic or clinic coursework to attend. Please let them know that you are applying to attend.

Question Title

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* 12. Are you interested in submitting an abstract for the poster session?July 1, 2024: Poster application deadlineAugust 1, 2024: Notification to applicants

* 12. Are you interested in submitting an abstract for the poster session?
July 1, 2024: Poster application deadline
August 1, 2024: Notification to applicants